The Tongue: What Dentists Should Know About Treating It

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The fields of medicine are largely divided based on organs or organ systems. Gastroenterologists treat the digestive system, cardiologists treat the cardiovascular system, pulmonologists treat the respiratory system, etc. Dentistry itself is largely defined by the treatment of teeth, although dentists also treat the entire oral cavity as well as the jaw and face. But which medical professional is responsible for monitoring the general health of the tongue? In their new book The Tongue, Andreas Filippi, Prof Dr med dent, and Irène Hitz Lindenmüller, Dr med dent, are putting forth the argument that dentists are the perfect candidates to treat the tongue and should therefore develop their knowledge base regarding its evaluation and treatment.

“There are a number of medical professionals who have the opportunity to observe a patient’s tongue,” Prof Filippi states. “Specialists and general practitioners alike regularly look into the oral cavity or throat of their patients. The tongue is the largest organ within this field of vision, yet practitioners have relatively little detailed knowledge about it. Dentists in particular see their patients’ tongues regularly during the course of routine dental check-ups, whereas an ear, nose, and throat specialist or general practitioner only gets to see the tongue when examination of the patient requires it.”

By nature, dentists have the most opportunities to observe and identify changes or pathologic signs in a patient’s tongue. However, there is a deficit in dentistry where knowledge of the tongue is concerned.

“In training as well as in continuing professional development,” Prof Filippi states, “relatively little attention has so far been paid to the tongue. This is evident in everyday clinical practice from uncertainties about the visible or sometimes invisible changes to the tongue—for example, burning tongue—that occasionally crop up. However, the tongue not only exhibits a multitude of normal variations and pathologic changes, but it also tends to reflect the general medical, internal, diet-related, and mental state of our patients. It cannot and should not be ignored.”

“Dental practitioners should always examine the tongue,” Dr Hitz Lindenmüller adds, “because the oral mucosa and especially the tongue mirror the health of the body and soul. The tongue can give you important information about pathologic disorders and systemic diseases that, often, even the patients are unaware of. Examining the tongue costs you 1 additional minute of time at maximum, yet it is worth that much and more because you acquire so much information about the patient’s oral and general condition.”

To drive her point home, Dr Hitz Lindenmüller provides the following example from her practice: “One day, a young female patient presented with papules on the gums and on the tongue. Based on those clinical findings as well as an examination of her arms and hands, it was discovered that the clinical findings were pathognomonic for a mucosal neuroma syndrome called Cowden syndrome. This diagnosis was significant because patients with Cowden syndrome are at increased risk of developing cancer; in fact, it was later found that her father, who died of cancer, likely shared the same gene mutation that causes Cowden syndrome.”

Prof Filippi offers practical guidance on exactly how dental practitioners should evaluate the health of the tongue. “During a thorough dental examination,” he advises, “the borders, underside, and base of the tongue as well as the floor of the mouth should be inspected as a basic principle. If there are any visible or merely palpable changes, further diagnostic investigation should be discussed and—depending on the results—suitable treatment initiated.”

In addition to its connection to generalized and systemic disorders and diseases, the tongue also plays an important role in many of aspects of routine dental care.

“The dorsal surface of the tongue is the only oral mucosa to have a microrough surface,” Prof Filippi explains. “Hence, the tongue harbors more than half of all oral microorganisms, which live there in a highly organized biofilm that protects them against chemical and mechanical influences. Aerobes are more likely to be found on the surface, and anaerobes can be found in the depth of the tongue. These anaerobes reside in the fissures of the strikingly rugged filiform papillae, which are only present on the dorsal surface of the tongue.

“Treatment of the consequences of microbiologic diseases in the oral cavity such as caries and periodontitis is the most common type of work done in dental practices. Some causal microorganisms may reside on the teeth or in the periodontal pockets, but a great many reside on the tongue. Even if great skill and effort is put into cleaning individual periodontal areas, this may not actually have a sustained impact on reinfection of the periodontium. Consider the current debate about the benefit of dental floss or the fact that the market introduces new toothbrushes each year that supposedly clean better than past toothbrushes. When it comes to caries prevention, clean teeth are only one consideration. In light of this growth of knowledge in prevention and therapy, modern medicine is fortunately focusing more and more on the largest site of oral microorganisms: the tongue. This is illustrated by examples such as full-mouth disinfection, modern halitosis treatment, and the idea of caries prevention by means of tongue cleaning. Fundamentally, dentistry should not concentrate solely on the teeth. It is not without reason that universities in many countries have departments such as Oral Medicine, Oral Diagnostic Sciences, or Oral Health—a trend that should spread across the globe.”

The health and function of the tongue also have an enormous impact on a patient’s quality of life. The functions of the tongue range from those that are necessary, such as speaking and moving food around in the mouth during mastication, to those that make life infinitely more enjoyable, like tasting. Prof Filippi emphasizes that all functions of the tongue deserve concern from practitioners when they are impaired in a patient.

“The tongue performs many important functions,” Prof Filippi explains, “and if one or more of those functions is restricted, quality of life can be greatly impaired. Many people suffering from advanced dysfunction or even complete loss of individual functions can also suffer from depression as a result. In addition to objective findings, subjective complaints also require careful evaluation. Articulation as well as the senses of touch and taste are so important to quality of life that patients who undergo radiotherapy to the head and neck area repeatedly report complaints. In addition to mucositis, these patients suffer severe impairment of their sense of taste—things taste differently or blander than usual. In some cases, patients develop aversions to particular foods and stop enjoying things they used to like eating. Fortunately, these sensory disturbances usually go away after oncology treatment is finished. Subjective complaints also play a growing role in the aging population, who often require drug treatment in the general medical practice. For example, a decrease in saliva flow rate is a common problem that can lead to redness, inflammation, fungal infections, and a burning sensation of the tongue. This frequently demands an interdisciplinary approach to provide satisfactory help to patients whose quality of life is often impaired.”

In order to address the gap in clinical knowledge regarding the tongue and to aid practitioners in diagnosis and treatment, Prof Filippi and Dr Hitz Lindenmüller developed their book The Tongue as a practical tool for clinicians.

“Today’s dental practitioners do not receive adequate education and training on the tongue,” Dr Hitz Lindenmüller explains. “We wrote this book to function as the missing link—to connect current research to clinical practice.”

“The aim of this book,” Prof Filippi states, “is to shed light on the tongue from the perspective of current academic literature. It is designed as an illustrated atlas and reference work rather than as a textbook in order to best serve clinicians when diagnosing and treating changes in the tongue. A further aim is to communicate the latest knowledge to students of dentistry and medicine for the benefit of their eventual patients.”

By strengthening their basis of knowledge regarding the tongue and its associated health concerns, clinicians will be able to provide better overall care to their patients and act as first responders by catching signs of underlying illnesses when symptoms elsewhere in the body may otherwise go unnoticed by the patient and the clinician. The result is a stronger standard of care that addresses the health of the largest organ in the oral cavity.

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Andreas Filippi, Prof Dr med dent, is Professor, Senior Physician, and Deputy Head at the Department of Oral Surgery, Oral Radiology, and Oral Medicine at the University Center for Dentistry of the University of Basel in Switzerland. He founded the Dental Accident Center in 2006 and the Center for Salivary Diagnosis and Drying of the Mouth in 2016. Prof Filippi is active in various professional societies and has published and lectured extensively in the fields of oral medicine and oral surgery.

 

Irène Hitz Lindenmüller, Dr med dent, is Senior Assistant at the Department of Oral Surgery, Oral Radiology, and Oral Medicine at the University Center for Dentistry of the University of Basel in Switzerland, where she has been in charge of oral mucosa consultations since 2001. Since 2008, she has also practiced as an oral surgery specialist in an orthodontic practice. Dr Hitz Lindenmüller is active in the field of oral medicine and oral surgery as a speaker and author of numerous technical papers.

 

The Tongue

Edited by Andreas Filippi and Irène Hitz Lindenmüller

As the largest organ in the oral cavity, the tongue not only plays a primary role in masticatory and speech function—it is also a significant indicator of health, demonstrating signs of both oral pathologies and diseases that can affect the entire body. Because no health care provider gets the opportunity to examine a patient’s tongue as often as the dentist, it is essential for dentists to recognize when there may be a problem with the tongue and what the problem is. In addition to an overview of tongue anatomy and general diagnosis and treatment recommendations, this book contains an atlas of more than 50 specific diseases and health concerns that may present signs and symptoms in the tongue. Each is outlined in a quick-reference table describing etiology, prognosis, and more and is accompanied by photographs of different ways the condition can present. A true diagnostic aid, this guide will allow clinicians to identify and address any abnormality a patient’s tongue may exhibit.

216 pp; 591 illus; ©2019; ISBN 978-0-86715-776-5 (B7765); $148